Interventional Radiology is full of various devices and materials. The general radiology resident needs to know these in order to impress the examiner. This file also contains information on various embolic agents.

1. CATHETERS,WIRES &
OTHER DEVICES IN IR
Dr.Saurabh Joshi, MD, FNVIR

2. Sven Ivar Seldinger

3. Simple 18 guage angiographic puncture needle - one-piece open needle with a sharp
beveled tip. guidewire is introduced directly through the needle once the tip is fully within the
bleeding vessel lumen. This style of needle can be used for both arterial and venous punctures.

7. Balkin’s Cross over sheath
Placed on contralateral side after crossing over the aortic bifurcation.
Facilitates easy access and treatment to lesions in the Iliac / SFA and high tibial arteries.

8. • Vascular sheath : Placed over the wire, through the access site. open at one end and
capped with a hemostatic valve at the other. Walls are non tapered – beveled to
closely match the dilator size so as to give a smooth transition between sheath and
dilator. Available in various lengths and diameters. Diameter of a sheath is measured
in “French”. Sheath selection is based on intended purpose
• Short 4 / 5 Fr sheaths for diagnostic purposes. Long sheaths with larger diameters for
interventions.

9. • Common guidewires. Left to right,Straight 0.038-inch; J-tipped 0.038-inch with
introducer device (arrow) to straighten guidewire during insertion into needle
hub; angled high-torque 0.035-inch; angled hydrophilic-coated 0.038-inch
nitinol wire with pinvise(curved arrow) for fine control; 0.018-inch platinum-tipped
microwire.

10. Basic construction of common guidewires.
1 and 2, Curved and straight safety guidewires with outer coiled
spring wrap, central stiffening mandril welded at back end only,
and small safety wire (arrow) welded on inside at both ends.
3, Movable-core guidewire in which mandril can be slid back and
forth and even removed completely to change wire stiffness, using
handle incorporated into guidewire (arrow).
4, Mandril guidewire in which soft spring wrap is limited to one end
of guidewire (arrow). Remainder of guidewire is a plain
mandril. 5, Mandril guidewire coated with hydrophilic
substance (arrow).

11. • Guidewires are available in a number of thicknesses, lengths, tip
configurations, stiffnesses, and materials of construction.
• Guidewire - the same as or slightly smaller than the diameter of the
lumen at the tip of the catheter or device that will slide over it.
• Too big will jam, usually at the tip of the catheter.
• If a guidewire is much smaller than the end hole of the catheter or
device, there will be a gap between the guidewire and catheter
that can cause vessel injury or prevent smooth movement over the
guidewire.
• Thickness measured in one hundrethds of an inch : 0.038
Inches,0.035 inches, 0.014 inches etc.

12. CATHETERS
• Common catheter shapes. 1, Straight; 2,Davis (short angled tip); 3, multipurpose
(“hockey-stick”); 4, headhunter (H1); 5,cobra-2 (cobra-1 has tighter curve, cobra-3
has larger and longer curve); 6,Rösch celiac; 7, visceral (very similar to Simmons
1); 8, Mickelson; 9, Simmons-2;10, pigtail; 11, tennis racket.

13. Flush catheters
• Allow high-flow injections into the
aorta or inferior vena cava.
• Uniform dispersal (with minimal
recoil) of contrast media via
multiple side holes.
• The tip is usually designed to help
center the shaft in the vessel and
prevent engagement and injection
into a branch vessel.
Selective catheters
• Have rotational stiffness to seek a
vessel orifice, but with enough
flexibility to pass the catheter far
into the vessel.
• Shaped in a particular way to seek
intended vessel ostium.

14. • Catheter outer size is described in French gauge (3F = 1 mm).
• Diameter of the end hole (and therefore the maximum size of the guidewire
the catheter will accommodate) is described in hundredths of an inch.
• The length of the catheter is described in centimeters (usually between 65
and 100 cm).
• The shape of the tip is named for either something the catheter looks like
(“pigtail,” “cobra,” “hockey stick”), the person who designed it (Simmons,
Berenstein, Rösch), or the intended use (celiac, left gastric, “head-hunter”)

15. COMPLEX CATHETERS
• Complex catheter shapes must be re-formed inside the body after insertion
over a guidewire.
• Any catheter will resume its original shape, provided there is sufficient space
within the vessel lumen and memory in the catheter material.
• Some catheter shapes cannot re-form spontaneously in a blood vessel,
particularly the larger recurved designs like the Simmons.

16. • Aortic spin technique for re-forming a Simmons catheter (works best for
Simmons 1). 1, Catheter is simultaneously twisted and advanced in proximal
descending thoracic aorta.

17. SELECTIVE CATHETERIZATION
Choosing a selective catheter shape:
A,Angled catheter when angle of axis of branch vessel from
aortic axis is low.
B,Curved catheter (e.g., cobra-2, celiac) when angle of axis
of branch vessel is between 60 and 120 degrees.
C,Recurved catheter (e.g., SOS, Simmons) when angle of
axis of branch vessel from aorta is great.

18. How to use a cobra catheter:
1. Catheter advanced to position proximal
to branch over guidewire, then pulled
down(arrow).
2. Catheter tip engages orifice of branch.
Gentle injection of contrast agent to
confirmed location.
3. Soft-tipped selective guidewire has
been advanced into branch.
4. Guidewire is held firmly, and catheter is
advanced.
5. Catheter in selective position.

19. How to use a Simmons catheter:
1. Catheter is positioned above
branch vessel with at least 1 cm of
floppy straight guidewire beyond
catheter tip.
2. Catheter is gently pulled
down (arrow)until guidewire and tip
engage orifice of branch.
3. Continued gentle traction results in
deeper placement of catheter tip.
4. To deselect branch, push catheter
back into aorta (reverse steps 1-3).

20. MICROCATHETERS
• Small catheters (3F or smaller outer
diameter) that are specially designed to fit
coaxially within the lumen of a standard
angiographic catheter are termed
microcatheters.
• Typically 2F to 3F in diameter, with 0.010- to
0.027-inch inner lumens.
• Designed to reach far beyond standard
catheters in small or tortuous vessels.
• Wide range of characteristics:
1. stiffness,
2. braiding,
3. flow rates,
4. hydrophilic coatings.

21. Progreat Microcatheter
This is a commonly used microcatheter in perpheral vasculature used
to facilitate embolization of Bronchial arteries, GI bleeds, Uterine Fibroid embolization etc.
This microcatheter allows embolization with microparticles as well as 0.018 coils.

22. Echelon 90 * Exelcior SL 10
These are microcatheters commonly used in embolization of intracranial
Aneurysms.

23. • When using a microcatheter, a standard angiographic catheter that
accepts a 0.038- or 0.035-inch guidewire is first placed securely in a proximal
position in the blood vessel.
• The microcatheter is then inserted through the outer catheter and
advanced in conjunction with a specially designed 0.010- to 0.025-inch
guidewire through the standard catheter lumen.
• Once a superselective position has been attained with the microcatheter, a
variety of procedures can be performed, including embolization, sampling,
or low-volume angiography.

24. GUIDING CATHETERS
• Designed to make selective catheterization and
interventions easier.
• These catheters can be used in some situations to help
position and stabilize standard catheters.
• These catheters can be used in some situations to help
position and stabilize standard catheters.
• They are used in circumstances in which standard
catheters are difficult to position selectively.

25. Guiding Catheter
These are large lumen catheters that are placed proximal to give stable position for
placement of instruments like microcatheters, coils, stents within target lesion.

26. Y Connector
These are connected on the hub of guiding catheters for haemostasis and
for placement
Of microcatheters as well as allow a continuous infusion of heparinized
saline from the side port.

27. Angioplasty Balloon
Shaft length , wire compatibilty, sheath compatibility
Radio opaque markers
Sizing
Max atm pressure
Principle of Angioplasty :
Plaque Fracture
Intimal Tearing
Medial Stretching

28. Self Expanding Stent
Have radial force that anchors stent to target vessel as it deploys.
Can be made of Nitinol that has thermal memory, they reach full expansion at
normal body temperature. Nickel titanium alloy.

29. Balloon Mounted Stent
Mounted over a balloon, expansion of the balloon
Causes deployment of this type of stent.
Precise positioning is required and is more rigid.
These are not placed over joints as can fractue.

30. Stent-grafts represent a combination of stent and surgical
bypass conduit technology. Internal bypasses.

31. Embolic Protection Devices

32. Atherectomy Device

33. Biliary Internal – External Drain
This has proximal as well as distal drainage
holes that allow drainage of bile proximal
to lesion externaly.
If the drain is internalised, that is the lesion
is crossed and distal end is placed in the
duodenum then bile is drained via the
proximal holes into the
Duodenum via distal holes.
Chiba Needle
Used to gain access to bilary ducts.
This can be done under Fluoroscopic
Or USG guidance.

34. Trapease Filter Greenfield filter
Used to prevent pulmonary embolism in patients with DVT in whom long
term anticoagulant therapy is contraindicated. Commonly placed in
infrarenal IVC after confirming negative jet of renal veins.
Can be permanent or temporary. Temporary filters have to be removed
within 6 weeks to prevent endothelization of the filter.

35. EMBOLIZATION AGENTS
Dr.Saurabh Joshi, MD, FNVIR

36. “
”
DELIBERATE OCCLUSION OF A BLOOD VESSEL TO
ACHIEVE A THERAPEUTIC RESULT

37. Technique has evolved to include nearly every vascular territory and has been used in
such diverse clinical applications as :

38. DEVICE SELECTION

39. PERMANENT LARGE-VESSEL OCCLUSIONS

40. PERMANENT SMALL-VESSEL OCCLUSIONS

41. TEMPORARY LARGE-VESSEL OCCLUSIONS

42. TEMPORARY SMALL-VESSEL OCCLUSIONS

43. GENERAL EMBOLIZATION SCHEME AND
CLINICAL INDICATIONS
Permanent Temporary
Large vessel
Coils (e.g.,
pulmonary
AVM)
Gelfoam
sponge (e.g.,
trauma)
Small vessel
Particles (e.g.,
UFE); no organ
death
Liquid agents
(e.g., renal
ablation);
organ death
Gelfoam
particles,
fibrillated
collagen (e.g.,
chemoemboliz
ation)

44. AUTOLOGUS CLOT :
Avantages : immediate availability, absence of cost, and lack of adverse
reaction.
Method : aspirate roughly 20 mL of the patient's blood and allow it to
clot, then discard the supernatant and reintroduce the clot through the
catheter. If desired, the clot can be opacified by adding sterile tantalum
powder.
Drawback : Rapid lysis time, which can lead to recanalization within 6 to
12 hours. This problem can be partially overcome by modification of the
autologous clot.

45. Gelfoam Pledgets Gelfoam Torpedo
If a very proximal occlusion is desired, Gelfoam "torpedoes" can be
formed by compressing and rolling strips of Gelfoam, which are then
loaded into the nozzle of a 1- or 3-mL syringe.

46. For more distal embolization, a slurry of Gelfoam can be created by macerating the
pledgets with two syringes and a three-way stopcock: the more passes the
Gelfoam makes through the stopcock, the more it is fragmented and the smaller
the pieces become.

47. Gelfoam embolization provides a temporary occlusion lasting
approximately 3 to 6 weeks.
Used for embolization of pelvic trauma or postpartum
hemorrhage, especially when there are multiple punctuate bleeding
sites from various branches of the internal iliac artery. In such situations,
embolization should be initiated with Gelfoam slurry to achieve a
relatively distal level of occlusion and then followed by Gelfoam
pledgets or torpedoes.

48. PVA Particles
Used in bronchial artery embolization,
Uterine fibroid embolization etc.

49. • Polyvinyl alcohol (PVA) is essentially a plastic sponge
that is fragmented and then filtered to a certain size
range.
• PVA is available in sizes between 50 and 2000 μm,
the typical size ranges used clinically are 300 to 500
μm or 500 to 700 μm.
• Smaller particles have a significant risk of tissue
infarction due to their distal level of occlusion. Larger
particles may occlude the delivery catheter

50. USES
• Predominantly for tumor embolization, either for
preoperative devascularization or as definitive
treatment, such as in uterine fibroid embolization,
JNA embolization.
• PVA can be used when treating hemorrhage of a
vascular bed with multiple small branches eg.
hemoptysis in patients with chronic inflammatory
lung disease.
• Prior to bronchial embolization, the presence of a
spinal artery originating from the treated vessel
should be excluded.

51. OTHER PARTICULATE AGENTS :
• Microspheres (Embosphere, BioSphere Medical, Rockland, MA).
• Embospheres are precisely calibrated, spherical, hydrophilic, microporous
beads made of an acrylic copolymer, which is then cross-linked with
gelatin.
• The hydrophilic surface prevents aggregation, allowing a more
predictable, uniform vessel occlusion than PVA, as well as easier delivery
through small catheters.
• SIR Spheres : Ceramic microspheres have been embedded with the beta
emitter Yttrium-90. Provide internal radiation of hepatic malignancies

53. USE OF PVA PARTICLES
Pre and Post Uterine Fibroid Embolization

54. EMBO CASE
• 11 yr old male child presented with recurrent nasal obstruction and epistaxis
since 2 months.
• ENT examination showed mass in the left nasopharynx.
• CT was done.

57. 1. STA
2. LA
3. FA
4. OA
5. APA
6. PAA
7. STA
8. IMAX
9. MMA

59. ECA EMBOLIZATION ..
Are there collaterals between ECA – ICA – VB circulations ?

60. Extra cranial Intracranial
Major artery Location Branch Branch Artery
Internal maxillary
artery
Proximal MMA
Orbital branches,
anterior branch
(anterior falcine artery)
Ophthalmic artery
Cavernous branches ILT
Petrous branch CN VII supply
Proximal AMA
Artery of foramen
ovale
ILT
Distal Vidian artery Petrous ICA
Distal
Artery of foramen
rotundum
ILT
Distal
Anterior deep temporal
artery
Ophthalmic artery
Superficial temporal
artery
Frontal branch Supraorbital branch Ophthalmic artery
Ascending pharyngeal
artery
Pharyngeal trunk
Superior pharyngeal
artery
Carotid branch
(foramen lacerum)
Lateral clival artery
Neuromeningeal trunk Odontoid arch Vertebral artery (C1)
Hypoglossal and
jugular branch
Meningohypophyseal
trunk of ICA
Posterior auricular-occiptal
artery
Stylomastoid branch CN VII supply
Occipital artery Muscular branches
Vertebral artery (C1–
C2)
Ascending and deep
cervical arteries
Vertebral artery (C3–
C7)
Summary of the major extra- and
intracranial anastomoses
•Note:—MMA indicates middle
meningeal artery; AMA,
accessory meningeal artery; ILT,
inferolateral trunk; ICA, internal
carotid artery; CN, cranial nerve.

61. Diagram of the functional vascular anatomy of the head and neck with the 3 major
extracranial–intracranial anastomotic pathway regions: the orbital, petrous-cavernous-clival,
and upper cervical regions.
Geibprasert S et al. AJNR Am J Neuroradiol 2009;30:1459-
1468
©2009 by American Society of Neuroradiology

62. Detachable Coils
Used in Intracranial Aneurysm
Coiling.
Pushable Coils
Used in Peripheral Embolization.

63. COILS
• First embolic coils consisted of pieces of stainless steel guidewires onto which
strands of wool had been woven to add a matrix for thrombus formation.
• Stainless-steel coils are best suited for high-flow applications due to their high
radial force, which helps prevent dislodging.
• Platinum coils are highly visible under fluoroscopy and are much softer than
stainless steel. This facilitates accommodation of the coil to the vessel.
• Appropriate sizing is important to ensure occlusion of the vessel at the intended
location.
• Gugliemi detachable coil : Coil is welded to the pusher wire in the desired
position, the wire is attached to a battery device that sends a current along the
wire. The current melts the welded connection between the coil and the wire
and detaches the coil without any force. GDCs are mainly used for treatment of
intracranial aneurysms.

64. USES
• Embolization with coils produces a focal occlusion, leaving the
vessel distal to the coil patent, similar to surgical ligature. Therefore,
coils are utilized in almost any application in which precise vessel
occlusion--but not tissue ablation--is necessary.
• Applications for coil embolization include treatment of hemorrhage,
occlusion of arteriovenous fistulas, and preoperative or pre-stent
graft vessel occlusion.

65. COIL EMBOLIZATION
27 yr old female patient with secondary PPH
Taken up for Uterine Artery Embolization.
Pre-Procedure Angiogram Shows :

66. 66
9/12/2014
Bilateral uterine arteries were embolised using pushable coils. There was no further bleeding.
Patient was stable.

67. 45 yr old female. Known diabetic. History of right thigh injury with soft tissue necrosis and continuous
bleeding. Hb falling by 3 gms a day. Angiogram showed :

68. ENDOVASCULAR COILING OF
INTRACRANIAL ANEURYSMS

69. LIQUID - POLYMERS
• Onyx : Liquid embolic agent, consisting of ethylene
vinyl alcohol copolymer dissolved in dimethyl
sulfoxide (Onyx, Micro Therapeutics Inc., Irvine, CA).
• Onyx contains tantalum powder to render it
radiopaque. After Onyx is injected into the target
lesion, the dimethyl sulfoxide solvent rapidly diffuses
away, causing precipitation of the polymer and
formation of a spongy cast.
• The cast solidifies from the outside in. Onyx allows a
prolonged, controlled embolization because of its
nonadhesive nature.
• Used mainly in Cerebral and Peripheral AVM
emboization

70. Onyx
Used for embolization of Cerebral AVMs,
Peripheral AVMs.

73. GLUE + LIPIDIOL
• n butyl cyanoacrylate.
• This agent is a permanent rapidly acting liquid,
similar to glues sold under trade names such as
"SuperGlue," that will polymerize immediately upon
contact with ions. It also undergoes an exothermic
reaction which destroys the vessel wall. Since the
polymerization is so rapid, it requires a skilled
surgeon. During the procedure, the surgeon must
flush the catheter before and after injecting the
NBCA, or the agent will polymerize within the
catheter. The catheter must also be withdrawn
quickly or it will stick to the vessel. Oil can be mixed
with NBCA to slow the rate of polymerization.
• ethiodol - Made from iodine and poppyseed oil, this
is a highly viscous agent. It is usually used for
chemoembolizations, especially for hepatomas,
since these tumors absorb iodine. The half life is five
days, so it only temporarily embolizes vessels.

75. SCLEROSING AGENTS
• Cause protein denaturation, leading to endothelial destruction and
vascular occlusion. Occlusion by sclerosants is usually permanent.
• Sodium tetradecyl sulfate (Setrol) and Polidocanol
• Uses : ablation of tumors, solid organs, veins, or vascular malformations.

78. THANK YOU